Testimonials

"As a wound expert I appreciate the web-based activities of Coloplast, and we will use part of the information in our in-house learning system. The assistance for selection of wound dressings on the basis of wound-related problems under attention of the phases of wound healing (wound selection wheel) is a powerful practical tool. The evidence website supports us with scientific background information we need for choosing the right product. The Coloplast College Program provides structured, up-to-date seminars given by outstanding wound experts."

“We appreciate the learning modules in the S.A.F.E programme put out by Coloplast in Canada. We have used them for our advanced practice nurses and also to supplement some of our own in-house learning. The topics covered by Dr. Sibbald and Laurie Goodman were very clear and concise. The Coloplast website is always given to our employees for their own self-directed learning. Whenever we have student nurses come for clinicals to our company, this website is also given to them and they are able to use the S.A.F.E. CD’s that we have in-house. Thanks again for all your support with our on-going educational needs.”

Patient report

When assessing and reporting on a patient, be sure to note the following:

Full medical history such as diabetes, vascular diseases, compromised immune system, connective tissue disorders and allergies

Medication

Nutritional status

Lifestyle, for example tobacco and alcohol habits or impaired mobility

Psychological problems

Quality of life

Wound assessment

Diagnosing the underlying cause of a wound is an essential part of wound assessment – and you can only treat the wound once this has been determined. You’ll also need to assess the wound bed and the surrounding skin. After you’ve made these assessments, you can select the best dressing.

Wound report

When assessing and reporting on a wound, you’ll want to note the following:

Wound location, size and type

Characteristics of the wound bed, such as necrotic tissue, granulation tissue and infection

References

The three most common types of leg ulcers are:

Venous leg ulcers (70%)

Arterial leg ulcers (10%)

Mixed venous and arterial leg ulcers (10–15%)

Venous leg ulcers

Venous leg ulcers are caused either by dysfunction of the venous valves or an inadequate calf muscle pump. In both cases, blood isn’t sufficiently returned to the heart. This leads to higher venous pressure, which can cause edema. And an increased fluid level between cells can result in cell death, leading to ulcers. This is why compression therapy is an essential part of treating venous leg ulcers.

Venous leg ulcers are often located in the gaiter area of the leg and characterized by:

Irregular shape

Brown pigmentation in the peri-ulcer skin area (often with eczema)

Normal foot pulse

Venous leg ulcers are often painful, especially during daytime. Elevation of the leg can relieve some of the pain.

Arterial ulcers

Arterial leg ulcers are caused by insufficient blood supply to the leg or feet due to arteriosclerosis. The condition reduces the supply of oxygen and nutrients to the cells, resulting in tissue death and, eventually, ulcers.Patients with arterial ulcers should not be treated with compression therapy, but will often need vascular surgery.

Arterial ulcers are often located in the gaiter area and on the feet, and are characterized by:

Fairly regular shape

Atrophic, pale peri-wound skin

Weak foot pulse

Arterial ulcers can be very painful, especially at rest.

Mixed venous and arterial leg ulcers

Mixed venous and arterial leg ulcers are ulcers caused by both venous and arterial disease. The majority of patients diagnosed with mixed venous ulcers have ulcers of venous origin and develop arterial insufficiency over time.

Treatment needs

Venous leg ulcers should normally be treated with graduated compression therapy. However, not all patients can tolerate full compression. Mixed aetiology ulcers are likely to require a reduced level of compression. Arterial leg ulcers should not be treated with compression therapy.

References

1. Lavery et al. Diabetes Care 2006;29(6):1288–93 2

Up to 15% of diabetics are likely to develop a foot ulcer at some stage in their lives. Diabetic ulcers have a considerable negative impact on patients’ lives, and are highly susceptible to infection that all too often leads to amputation. This makes infection control of paramount importance in diabetic foot ulcer management.

Successfully managing a diabetic foot ulcer requires a comprehensive understanding of the wound: its cause, progression, risk, and treatment.

The main causes of diabetic foot ulcers are:

Neuropathy

Poor blood supply (ischemia)

Neuropathy

Neuropathy is the most common diabetic foot condition and is caused by damaged nerves in the lower extremity. The condition is permanent and can lead to loss of sensation, which increases the risk of accidental injuries, and painful feet. Treatment involves attention to feet, self-care and custom-made footwear.

Poor blood supply (ischemia)

A very serious condition, ischemia, is the main reason for amputations. Ischemia is caused by impaired circulation, which can be due to arteriosclerosis or occlusion of tissue. Impaired circulation causes reduced pulse – the foot is cold and blue – and this leads to tissue death and the eventual development of an ulcer. Your patient may need vascular surgery.

Infection

Diabetes can change the body’s ability to combat infection. Not only are the feet more prone to infection, it’s also harder to get rid of an infection once it’s there. So it’s crucial that you assess the patient regularly to prevent and react quickly to infections.

Treatment needs

Treat the underlying causes of a diabetic foot ulcer if possible

To support the healing process, use appropriate moist wound healing dressings with superior absorption and exudate management properties, such as Biatain Non-Adhesive or Biatain Alginate dressing

A pressure ulcer (decubitus ulcer) is a localized injury to the skin and/or underlying tissue, usually over a bony prominence. This type of ulcer is the result of pressure, or pressure in combination with shear (2). The pressure prevents the blood from circulating properly, and causes cell death, tissue necrosis and the development of ulcers. Wheelchair users or people confined to a bed (for example, after surgery or an injury) are especially at risk.

Major cause of morbidity

Pressure ulcers are a major cause of morbidity and mortality, especially for people with impaired sensation, prolonged immobility, or advanced age. The most common places for pressure ulcers are over a bony prominence, such as elbows, heels, hips, ankles, shoulders, the back, and the back of the head.

Classification

Pressure ulcers are classified according to the degree of tissue damage observed. In 2009 the EPUAP-NPUAP advisory panel agreed upon four levels of injury (3):

Category/Stage I: Non-blanchable redness of intact skin

Buttocks, Stage I, NPUAP copyright & used with permission.

Intact skin with non-blanchable erythema of a localized area, usually over a bony prominence. Discoloration of the skin, warmth, edema, hardness or pain may also be present. Darkly pigmented skin may not have visible blanching.

Category/Stage II: Partial thickness skin loss or blister

Buttocks, Stage II, NPUAP copyright & used with permission.Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled or serosanginous-filled blister.

Category/Stage III: Full thickness skin loss (fat visible)

Ischium, Stage III, NPUAP copyright & used with permission.

Full thickness tissue loss. Subcutaneous fat may be visible, but no bone, tendon or muscle is exposed. Some slough may be present. May include undermining and tunneling.

Category/Stage IV: Full thickness tissue loss (muscle/bone visible)

Sacral Coccyx, Stage IV, NPUAP copyright & used with permission.

Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often include undermining and tunneling.

Category/Stage: Unstageable

Full thickness skin or tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed.

References

An acute wound is an injury that causes a break in the skin and sometimes the tissue. Acute wounds are classified into two principal types:

Acute traumatic wounds, such as abrasions, lacerations, penetrations or bites, and burns

Acute surgical wounds resulting from surgical incisions

Acute wounds – signs and symptoms

A cut or tear in the skin

Bleeding, swelling, pain, and/or difficulty moving the affected area

There may be dirt or foreign objects inside the wound

Exudate is normally clear

Large or deep, acute wounds with heavy bleeding need acute medical attention to stop bleeding and check for damage to vital organs or tissue.

Treatment needs

Foreign objects should be removed from the wound and necrotic tissue debrided, as it can function as a base for infection and delay wound healing. Wound cleansing with SeaClens Wound Cleanser, may be appropriate.

Exudate production is part of the natural wound healing process (1), but the exudate needs to be managed appropriately. Exudate levels are often high during the inflammatory phase of wound healing, and leakage of exudate under the dressing can damage the surrounding skin. Wound exudate must be absorbed and managed by a dressing with moist wound healing properties. This supports the healing process and reduces scar formation. (2-3)

With appropriate care, smaller acute wounds will normally close within days or weeks depending on the size, depth and position of the wound.

Suitable dressings for acute wounds are dressings with superior absorption and exudate management properties that support a moist wound healing environment. These include Biatain Silicone, Biatain Adhesive or Comfeel. Where infection is present, Biatain Silicone Ag and Biatain Ag are appropriate choices.

Wound and skin condition

Necrotic tissue is often black or yellow. It may be soft or it may form a scab (eschar). Necrotic tissue can contain bacteria – and if the bacteria grow, the wound will become infected.

Removal of necrotic tissue (debridement)

Necrotic tissue must be removed in order to support wound healing. Removal can be surgical, mechanical, enzymatic (such as maggot therapy), or it can be achieved by supplementing the body’s own ability to break down necrotic tissue (autolytic debridement).

Choice of dressing

The autolytic debridement process is optimized when the wound is moist. Coloplast has a range of dressings that support moist wound healing. For optimal moisture balance in the wound, the hydrocolloid Comfeel dressing, Triad hydrophilic wound dressing, and the unique properties of the Biatain foam dressing each support the natural autolytic debridement process.

Purilon gel is ideal for gentle and effective autolytic debridement of tissue in both dry and moist necrotic wounds, when used in combination with a secondary dressing such as Comfeel or Biatain.

Maceration

Exudate leaked from ulcers can cause maceration, a softening or sogginess and breakdown of the skin that results from on-going contact with excessive moisture. Maceration can lead to skin breakdown, causing the wound to grow or creating satellite ulcers. Macerated tissue is white in color.

Erythema

Erythema is an abnormal redness of the skin caused by dilation of blood vessels. Redness of the peri-wound skin may be a sign of inflammation or wound infection.

Fragile skin

As we grow older, the texture of our skin changes and our skin becomes thinner, weaker and less protective. If a wound is surrounded by fragile skin, dressings are more likely to cause skin irritation. You must examine the skin carefully before deciding to use either an adhesive or a non-adhesive dressing.

Choice of dressing

The Biatain dressing range offers dressings with superior absorption and exudate management properties for all types of skin conditions.

If a wound is surrounded by fragile skin, a dressing with silicone adhesive such as Biatain Silicone is an excellent alternative, as it can be used on both fragile and healthy skin.

Normal, healthy skin has a smooth and resilient structure. With proper wound treatment and use of dressings with superior absorption and exudate management, the skin surrounding a wound may be perfectly healthy and suitable for adhesive dressings such as Biatain Adhesive or Biatain Super, Adhesive.

In the inflammatory phase of wound healing, exudate levels are usually high. Non-healing, or chronic, wounds are often stuck in the inflammatory phase and may produce large amounts of exudate. Increased exudate levels can be a symptom of infection and increased oedema.

Wound exudate is a fluid composed of plasma, blood cells and platelets. Most of the wound exudate filters from the blood and/or lymph system into the wound area, but red blood cells and platelets leak from injured capillaries. Composition and viscosity varies, from thin and clear plasma fluid to thick yellow secretion containing high concentrations of white blood cells and bacteria.

Controlling exudate

If wound exudate is not properly controlled, it can leak from the dressing and result in the peri-wound skin being exposed to the exudate (1). This causes over-hydration maceration of the skin and can ultimately delay healing (2,3).

Maceration is a softening or sogginess and breakdown of the skin caused by on-going contact with excessive moisture. Macerated tissue looks white and maceration can cause an ulcer to grow or create satellite ulcers.

Macerated skin(2,3)

Delays healing

Increases risk of infection

Increases friction risk

Can result in wound enlargement

It is therefore very important that excess exudate is removed from the wound by an absorbent dressing. (4)

Control of exudate, removal of unhealthy tissue by debridement and management of bacterial load are all part of good wound bed preparation. The optimal wound dressing keeps the wound moist and absorbs exudate, locking it inside the dressing to prevent maceration.

Dressings for exuding wounds

We recommend the Biatain dressing range, which provides superior absorption - of low to high exuding wounds. Biatain dressings effectively absorb and retain wound exudate, ensuring a moisture balance that is optimal for wound healing. (7,8)

Wounds that are not healing normally may have a bacterial imbalance resulting in local infection of the wound.

Likely signs of wound infection are one or more of the following:

Delayed or stalled healing

Odor

Increased wound exudate

Absent/abnormal/discolored granulation tissue

Increased pain at wound site

Other symptoms

Additional clinical symptoms may arise if the infection spreads to the healthy tissue surrounding the wound. Depending on the type of bacteria, the wound exudate may become more puss-like, and the peri-wound skin may be tender, red and painful. The patient may also have a fever.

Please remember that diabetic foot ulcers do not always present with the classical signs of local infection.

Dressings for infected wounds and wounds at risk of infection

If a wound is healing normally, a foam dressing with superior absorption such as Biatain or Biatain Silicone is ideal. If the wound is infected or there is risk of wound infection, we recommend silver dressings such as Biatain Ag, Biatain Silicone Ag or Biatain Alginate Ag. These provide superior absorption for infected wounds (1-7). If the infection is spreading beyond the wound, the silver dressing must be combined with systemic antibiotic treatment at the discretion of a physician.

Case studies

The patient

The patient – an 85-year-old woman – had been suffering from a venous leg ulcer on the lateral part of her lower left leg. The skin on her leg was fragile. The ulcer had persisted for five months at inclusion.

Previous treatment

Prior to inclusion, the ulcer had been treated with alginate dressings and compression therapy for ten weeks. Ulcer healing was delayed compared to the normally expected healing rate.

Biatain Non-Adhesive introduced

When the patient began treatment with Biatain Non-Adhesive, the ulcer area was 4.9 cm2. The ulcer contained 20% fibrinous tissue and 80% healthy granulation tissue. During the four-week treatment period, long-stretch compression bandages were applied.

This picture shows the ulcer at inclusion after cleansing:

Ulcer area was reduced by 73% after two weeks of treatment with Biatain Non-Adhesive:

The ulcer area was reduced by 95% after 4 weeks of treatment with Biatain Non-Adhesive:

Conclusion

During the four weeks treatment period:

Biatain Non-Adhesive demonstrated remarkable reduction in ulcer size.

Biatain Non-Adhesive caused no leakage or maceration, even under compression therapy.

The patient

This patient suffered from heart failure, coronary heart disease, arterial hypertension and venous insufficiency in both lower limbs, as well as Alzheimer’s.

Deep foot ulcer

For four months, she had a very deep diabetic foot ulcer on the right foot with erythema, oedema, crepitation and heat in the surrounding tissues. She was referred to the A&E department and after examination by Vascular Surgery, her family was informed that the immediate treatment would involved supracondylar amputation since she was suffering from a grade 4–5 diabetic foot based on the Wagner scale.

Biatain Ag introduced

The family was opposed to this treatment, and the patient was returned to her home for monitoring by her family doctor and out-patient care and dressing by home nursing. Biatain Alginate Ag and Biatain Ag were used in combination with debridement and oral antibiotics.

This picture shows the ulcer at inclusion:

This picture shows the ulcer after five weeks of treatment with first Biatain Alginate Ag and then Biatain Ag Non-Adhesive:

Here we see the ulcer after four months’ treatment:

The ulcer was closed after 10 months’ treatment:

Conclusion

The objective set was to prevent amputation of the foot, ensure the well being and comfort of the patient and of the family. The method used began to bear fruit already seven days after the treatment started, with visible changes in the development of the wound. The wound closed ten months after the treatment was started.

The patient

The patient was an 88-year-old woman with a highly exuding Stage III sacral pressure injury. The ulcer had persisted for two months and had previously been treated with standard moist wound healing products.

The ulcer

The ulcer had several signs of local infection, a significant odour, and was heavily exuding. A small undermining was present at the top of the ulcer and there was approximately 50% unhealthy necrotic tissue in the wound bed.

Biatain Ag Adhesive introduced

Odour was eliminated after just one week of treatment:

This picture shows that the wound bed is clean and healing is progressing after four weeks of treatment:

Conclusion

During the one-month treatment period Biatain Ag effectively eliminated signs of local infection and supported healing of this heavily exuding sacral pressure injury. Elimination of odour and a significant increase in healthy granulation tissue was observed already after one week.

Wound Care Organizations

American Academy of Dermatology

The academy members include practicing dermatologists who are committed to excellence in patient care, medical and public education, research, professionalism and member services support . Learn more about this academy at www.aad.org.

Association for Professionals in Infection Control and Epidemiology

APIC is a professional association dedicated to improving health and patient safety by reducing risks of infection and other adverse outcomes. Learn more about this association at www.apic.org.

Association for the Advancement of Wound Care

AAWC is a non-profit association for anyone involved in wound care. Join in to learn more about wound care at www.aawconline.org.

Diabetic Foot Study Group

The aim of the DFSG is to promote improvements in diabetic foot care. Read more about this group at www.dfsg.org.

European Pressure Ulcer Advisory Panel

EPUAP works to lead and support all European countries in the efforts to prevent and treat pressure ulcers. You can learn more about their activities at www.epuap.org.

European Wound Management Association

The EWMA deals with all clinical and scientific issues related to wound healing. Each year, EWMA hosts one of the largest international events within wound management and wound healing in Europe. Learn more about this association at www.ewma.org.

International Working Group on the Diabetic Foot

IWGDF works to improve outcomes of diabetic foot problems and strengthen the communication between healthcare professionals. Learn more about their work at www.iwgdf.org.

International Association for the Study of Pain

IASP is the world's largest multidisciplinary organization working to support the study of pain and to translate that knowledge into improved pain relief worldwide. Read more about them at www.iasp-pain.org.

National Pressure Ulcer Advisory Panel

NPUAP is an American organization working for the prevention and improved treatment of pressure ulcers. Read more at www.npuap.org.

Strategic Marketplace Initiative (SMI)

A consortium of executives representing healthcare providers; medical products, pharmaceuticals and supply chain distribution companies; and service businesses united to reengineer and advance the future of the healthcare supply chain for the purpose of improving the overall healthcare marketplace in the United States. Learn more by visitingwww.smisupplychain.com.

World Wide Wounds

World Wide Wounds is an electronic wound management journal dedicated to providing practical guidance and information on all aspects of wound management to healthcare professionals worldwide. Read the journal at www.worldwidewounds.com.

Wound Healing Society

The Wound Healing Society is a non-profit organization for clinical and basic scientists dedicated to improve the area of wound healing. Learn more about their activities atwww.woundheal.org.

Wound, Ostomy and Continence Nurses Society

The WOCN Society is a professional nursing society. It supports its members by promoting educational, clinical and research opportunities to advance the practice of expert healthcare to individuals with wounds, ostomies and incontinence. Read more about this society atwww.wocn.org.

World Union of Wound Healing Societies

WUWHS is an international organization dedicated to improving the wound care standards for patients and the healthcare performance of professionals. It also works to ensure universal access in all healthcare systems. For more information go to www.wuwhs.org